Resource effects on access to long-term care for frail older people

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Willingness to Use Formal Long-Term Care Services by Korean Elders and Their Primary Caregivers

This study examined predictors of older adults' and primary caregivers' willingness to use formal long-term care (LTC) services to understand possible use patterns of mandatory public LTC insurance programs in Korea. It focused on views regarding who (adult children or the government) should bear the responsibility for older adults' care. Logistic regression models were estimated using data from 1,168 older Korean adults aged 65 or older and their primary caregivers from a national survey. The results showed that older adults' and their caregivers' views on care responsibility were a dominant predictor of their willingness to use both formal home care services and nursing home care services. Both older adults and their family caregivers' willingness to use LTC services should be considered when predicting demand for LTC services. Efforts should promote the perspective that formal LTC services are an acceptable social norm.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Strengthening home and community-based care through Medicaid waivers

States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care (LTC). We examined state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals. State level data for the period 1992 to 2001 were used to estimate random effects panel models. States with increased community-based care (e.g., home health agencies) and decreased nursing home bed capacity were positively associated with state per capita rates of use, expenditures, and the share of Medicaid LTC dollars supporting 1915c waivers. States appeared to substitute Medicare for Medicaid services for individuals eligible for both. State per capita income was positively related to each measure. State policies that facilitate decreased institutional and increased community- based capacity appear essential to state efforts to expand access to community-based services. Federal policies that address state resource issues may also spur growth in community-based LTC, which, in most states, continues to be limited.     

State commitment to home and community-based services: effects on independent living for older unmarried women

This study examines the impact of state variation in commitment to the provision of home and community-based services on the living arrangement outcomes of older unmarried females with functionallimitations. We combine data from the 1990 U.S. Census of Population (PUMS) with state-level information on long-term care home and community- based service expenditures, nursing home bed availability, and Medicaid nursing home costs from a special report that compares state variation in long-term care systems. Using multilevel logistic regression modeling techniques, we find that the risk of institutionalization compared to community living arrangements is reduced as spending for home and community-based services at the state level increases. We discuss these findings in light of policy changes during the 1990s.     

The Effect of Long-Term Care Insurance on Home Care Use Among the Disabled Elders

Using the 1998?C2004 Health and Retirement Study, this study uses Cox??s model to explore the effects of private long-term care insurance ownership on first home care use among the disabled elderly. Results show that long-term care insurance ownership and Medicaid eligibility did not significantly increase the likelihood of using home care services, while income and homeownership lowered this likelihood. Functional limitation was the key determinant of home care use and those who lived with children were less likely to use home care services. Based on the findings, this study provides foundations for long-term care policies and long-term care planning programs.     

Transition from home care to nursing home: unmet needs in a home- and community-based program for older adults

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.     

“We Have to Create Family”: Aging Support Issues and Needs Among Older Lesbians

Gay and lesbian seniors are more likely to be single, live alone, and be childless. The current evidence base suggests that limited social supports are associated with a variety of health disparities among all older adults. Research regarding the aging issues of lesbian seniors is scarce. This instrumental collective case study of 4 older lesbians (ages 59 and older) illustrates unique aging support concerns, issues, and needs. The purpose of the case study is to increase provider sensitivity and provide supportive evidence of the need for more research. Findings suggest that limited biological family support, childlessness, and “families of choice” may be important factors in support service and health care decisions for older lesbians. Implications for care providers in working with the older lesbian population include exploring existing supports and assisting with the formation of culturally acceptable support systems and services. Given the current evidence base regarding the impact of social support on elder health, it is critical for providers to have a better understanding of elder lesbians’ unique concerns and needs relating to support and health care services in order to prevent health disparities among this vulnerable population.     

Race and gender differences in the distribution of home and community-based services in Florida

This article examines the distribution of home and community-based services (HCBS) under Florida's Medicaid waiver program. Controlling for personal and community characteristics, it was found that gender and race significantly affect the access of the disabled adult population to HCBS services, with women and nonwhites significantly more likely to be receiving HCBS services. At the county level, the likelihood of one's being in the waiver program is contingent on the racial composition and level of segregation of the county. People residing in counties with substantial proportions of nonwhites are less likely to receive HCBS services--whatever their race. However, the higher the rate of racial segregation in the county, the higher the probability that the Medicaid disabled adult population will receive HCBS services. The Medicaid waiver program allows older, disabled black women to remain in their home neighborhoods rather than having to move to predominantly white areas where nursing homes are concentrated. Thus, the HCBS program not only provides them with a form of care that is preferred by most older people but also resolves market problems stemming from the lack of nursing homes in segregated areas by taking advantage of support systems in black households.     

Religious homogamy and voluntary childlessness in Canada

The aim of this study was to determine the influence of religious affiliation, religious homogamy, religiosity, and religious marriage on voluntary and temporary childlessness and to compare childlessness patterns among Canadian-born and foreign-born women. Data were obtained from the 1984 Canadian Fertility Survey of 2863 women aged 18-49 years who were married to their first husband or living in consensual unions. The sample included 216 childless women, of whom 98 were voluntarily childless and 91 were temporarily childless. Analysis performed with probit maximum likelihood techniques and bivariate forms revealed that homogamous Catholics were less likely to remain temporarily childless but more likely to be voluntarily childless than non-Catholics. Multivariate analysis found that age, marriage age, education, and husband's income were statistically significantly related to voluntary childlessness. The likelihood of childlessness was also influenced by young age, later marriage, higher education, employment, women with husbands with lower income, and women who attend church services less frequently. Religious homogamous marriage was unrelated to childlessness. Frequent church attendance decreased the odds of deciding not to have children. Neither Catholic homogamy nor non-Catholic homogamy had an important effect after interaction terms for both religiosity and homogamy were included. Childlessness among foreign-born women was significantly more likely among those whose husbands had lower income, nonreligious women, and non-Catholic women who married heterogamously. Canadian women's childlessness was significantly related to education, husband's income, religiosity, and non-Catholic homogamy.     

Nursing home ownership: an historical analysis

The need to care for dependent elderly in the United States has been a constant since colonial times. Today, as in the earliest days, most care is provided at home by family members. Personal and health services outside the home are sometimes provided by nursing homes. The nursing home industry is large, dominated by private, for-profit ownership, and receives much of its income from public funds. Why are nursing homes publicly funded? Why are nursing homes privately rather than publicly owned? Why is ownership for-profit or proprietary rather than not-for-profit or voluntary? The answers to these questions are found in the history of social policies in the United States.     

A 10-foot rope for a 50-yard drop: the CLASS Act in the patient protection and Affordable Care Act

The Community Living Assistance Services and Supports (CLASS) Act, part of the 2010 health care reform, would have paid a daily cash payment toward the costs of long-term care. This article points out that although the CLASS Act may have been sufficient to cover the costs of most home- and community-based services, it was an inadequate response to the most pressing long-term care financing problem facing baby boomers: nursing home care costs. The risk of needing a nursing home is higher than other catastrophic risks. Boomers lack savings to pay those costs. CLASS aimed to encourage people to use home- and community-based services to substitute for nursing home care, but research spanning decades shows there is little substitution effect.     

Older lesbians' experiences with home care: Varying levels of disclosure and discrimination

ABSTRACT

There is considerable evidence that lesbian, gay, bisexual and transgender (LGBT) older adults have experienced barriers to health care access and have profound fears about how they will be treated in the long-term care system, but the specific experiences of older lesbians have received less attention. Most older adults needing long-term services and supports (LTSS) prefer to remain at home, and this is true for lesbians as well. This article reports on a national, qualitative study of the experiences of 20 older lesbians (age 65 and older) with home care workers. The experiences of six informal partner caregivers with home care services are also included. Emergent themes regarding level of disclosure, experiences with homophobia, evaluation of care received, and thoughts about ideal LTSS are described. Most study participants did not disclose their sexual orientation to their home care workers. A significant minority experienced homophobia, but nearly all ultimately found workers who provided good care with which they were comfortable. Their visions of ideal LTSS included greater affordability and particular qualities that were important for home care workers to possess, such as competence, caring and acceptance. Practice and policy implications are outlined including careful recruitment, training and supervision of home care workers to foster lesbian-sensitive care, but also improved wages and work conditions in order to maintain a quality home care workforce.     

Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home

Few empirical studies have focused on elder abuse in nursing home settings. The present study investigated the prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care in Michigan. A random sample of 452 adults with elderly relatives, older than 65 years, and in nursing home care completed a telephone survey regarding elder abuse and neglect experienced by this elder family member in the care setting. Some 24.3% of respondents reported at least one incident of physical abuse by nursing home staff. A logistic regression model was used to estimate the importance of various risk factors in nursing home abuse. Limitations in activities of daily living (ADLs), older adult behavioral difficulties, and previous victimization by nonstaff perpetrators were associated with a greater likelihood of physical abuse. Interventions that address these risk factors may be effective in reducing older adult physical abuse in nursing homes. Attention to the contextual or ecological character of nursing home abuse is essential, particularly in light of the findings of this study.     

Childlessness Among Older Women in the United States: Trends and Profiles

In the last 2 decades, the United States has seen an increase in childlessness and first births at older ages. Using the National Survey of Family Growth, we focus on women aged 35 – 44 who are voluntarily childless (expect no children and are fecund or contraceptively sterile). We compare these women to those who are involuntarily childless (fecundity impaired) and to those who are temporarily childless (expect children). Voluntary childlessness grew from 1982 (5%) to 1988 (8%), was stable up to 1995 (9%), and fell slightly in 2002 (7%). Voluntarily childless women have the highest income, prior work experience, and lowest religiosity compared to other women. This has been true since 1982, the earliest time point examined.     

EDITORIAL

ABSTRACT

Data from Cycle 5 of the National Survey of Family Growth (NSFG) (1995) were analyzed to identify factors that could predict whether a woman 18-44 years of age would ever have sought to adopt a child. Of the 10,019 women in the specified age group overall, 508 (5.1 percent) had ever sought to adopt, including 5.4 percent of white women and 5.2 percent of black women. Multiple logistic regression analyses were conducted for all women and for white women and black women separately. Among women who were white, the likelihood of having ever sought to adopt increased under conditions of childlessness, a history of treatment for infertility and surgical sterility for non-contraceptive reasons, non-surgical sterility, or physical difficulty in becoming pregnant (subfecundity), and if the woman was married, older, had some amount of college education, and considered religion very important. Having received assisted reproductive technology treatment also increased the likelihood that women in this group had sought to adopt. The likelihood of having ever sought to adopt increased among black women who were childless, older, and surgically sterile for non-contraceptive reasons, non-surgically sterile, or subfe-cund. However, having been treated for infertility and the presence of “resource” variables (other than age) did not predict that black women would have sought adoption. Among women of all races, having been a foster parent to a child increased the likelihood that the woman had sought to adopt the child when the woman was also childless, had been treated for infertility, was non-surgically sterile or subfecund, and older. Having been a foster parent was a significant predictor among white women who were childless and had ever been treated for infertility. Results are discussed in terms of benefits and limitations of all analyses and in terms of their implications for practice, policy, and research.     

Increasing Childlessness in Germany and Japan: Toward a Childless Society?

Abstract: This paper focuses on childlessness in Germany and Japan and its sociological meanings in family formation in postmodern societies. First, it shows the trends of fertility decline and increasing childlessness, and clarifies the similarities and differences in both countries, by comparing parity composition, educational attainment, and other socioeconomic correlates of childlessness. Second, using the data of attitudinal surveys, such as the 2003 Population Policy Acceptance Study (PPAS) in Germany and the 13th National Fertility Survey (JNFS; 2005) in Japan, the reasons for having no children are observed. Third, referring to the discussions of German scholars, it tries to explain the sociological meanings of childlessness and to describe the development toward a childless society (even if it's demographically not sustainable) as one of the possible consequences of the Second Demographic Transition. Important findings are as follows: (1) In Germany the fertility decline began early in the mid-1960s but in Japan later from mid-1970s so that the increase of childlessness has been a little delayed. The proportion of childless women in Western Germany increased to 28% for the 1967 cohort. In Japan, it has increased to 12.7% for the 1960 cohort, but is expected to reach 30% for the 1970 cohort. (2) The educational gap in childlessness is clearly observed in Germany; however, this is not so simple in Japan. Corresponding with the increase of childlessness, the desired number of children in average is declining. The emergence of a child-free culture is observed in Germany by PPAS, but not yet in Japan by JNFS. (3) Polarization may proceed further in both countries, between childless people and people with many children.     

Client satisfaction with live-in and live-out home care workers in Israel

In an era of globalization where the migration of longterm care workers is common, foreign live-in home care workers can compensate for the unavailability of family members and, perhaps, even substitute for institutional care in the provision of long-term care services to disabled older persons. This study examines differences in home care satisfaction between disabled older persons in Israel with "live-in" home care workers and those with "live-out" workers, and explores some differences in sociodemographic and personal characteristics between these two groups. Face-to-face interviews were held with a random sample of 93 older persons in Beer-Sheva. Older persons with live-in home care workers were more satisfied with their home care service than those with live-out workers. Those with live-in workers were more severely disabled, tended not to have any children living in close proximity, although an adult child was available as an informal caregiver. Communication difficulties between the elderly persons and their home care workers were found not to affect negatively the satisfaction with the service.     

Mental health service utilization in children adopted from US foster care,US private agencies and foreign countries: Data from the 2007 National Survey of Adoption Parents (NSAP)

Aims

In this analysis, we (1) described the rate of mental health service utilization for children from domestic foster care adoption, domestic private adoption, and international adoption and (2) analyzed the effect of common risk factors on mental health service utilization.

Data

As part of the 2007 National Survey on Adoptive Parents (NSAP), parents with children 5–17 years old (N = 1722) were asked if their children had received mental health services and how helpful these services were. Parents also provided data on the children's demographics and likelihood of pre-adoption adversity (e.g., abuse).

Results

For boys, mental health services were utilized by 52.4% of domestic foster care adoptees, 41.0% domestic private adoptees, and 40.0% of international adoptees. For girls, the corresponding rates were 36.3%, 24.8%, and 30.9% respectively. Parents reported that the services were very helpful for about half of the children. Logistic regression analyses showed that adoptees from domestic foster care were more likely than international adoptees to have received mental health services, but there was no difference between domestic private adoptees and international adoptees. Older age at placement, older age at assessment, having special health care needs, and being male all increased the odds for having received mental health services.     

Does the Reason Matter? Variations in Childlessness Concerns Among U.S. Women

Does the reason why women have no children matter with regard to level of childlessness concerns? Reasons include biomedical barriers, situational barriers, delaying motherhood, and choosing to be childfree. The concept of “childlessness concerns” captures the idea that holidays and family gatherings are difficult because of not having children or feeling left out or sad that others have children. Life course and identity theories guided the structural equation model analyses of a representative sample of 1,180 U.S. women without children from the National Survey of Fertility Barriers. The results indicated that women with the least control over pregnancy, those with biomedical barriers, had the highest childlessness concerns. As hypothesized, the association between reasons and childlessness concerns was mediated by the identity‐relevant measure, importance of motherhood. Contrary to the authors' hypothesis, the association was not mediated by social messages to have children. Thus, it is primarily involuntarily childless women who have high childlessness concerns.